A cluster-randomized trial of a complex intervention to encourage deprescribing antidepressants in nursing home residents with dementia: a study protocol

Abstract

Background The effectiveness of psychotropic medication on behavioral and psychological symptoms of dementia (BPSD) is limited, while associated with a higher risk of adverse events. Non-pharmacological treatment of BPSD is advocated as treatment of first choice. However, many general practitioners (GPs) find it difficult to initiate deprescribing, and when attempting to discontinue psychotropic medication in nursing home residents, they face many barriers. Therefore, we hypothesize that an intervention aimed at improving communication with and involvement of nursing home staff, relatives, and patients by GPs can optimize the pharmacological treatment of BPSD. The aim is to reduce the use of antidepressants in nursing home residents with dementia without increasing morbidity or mortality. Objective The primary outcome is reduction of antidepressant. Secondary outcomes include difference in use of other psychotropic medication, mortality, morbidity, and severity of BPSD. Method The study is a cluster-randomized controlled trial based in general practices in Denmark. We aim to include 22 practices, each of which will recruit up to 15 patients with dementia living in nursing homes. The intervention period is 3 months, and the total study period is 1 year. Randomization is 1:1 to intervention and control group by computer algorithm. Both groups receive education on BPSD and its evidence-based treatment. The intervention includes three tailored components; (1) teaching material and training to be used by the GP to educate nursing home staff on BPSD, (2) a pre-visit reflection tool to encourage nursing home staff to evaluate symptoms and reflect on relatives involvement in the discontinuation process; and (3) a dialog tool to facilitate shared decision making on optimization of BPSD treatment during the visits at the nursing home. The control group includes enhanced care as usual. The primary and secondary outcomes will be assessed at the end of the study period. A process evaluation will be conducted to assess the implementability. Discussion We anticipate that the intervention will optimize the treatment of BPSD with antidepressants for nursing homes residents and enhance compliance with reduction of medication. The process evaluation should provide insights into the barriers and facilitators to changing the current practice of deprescribing. Trial registration Clinicaltrials.gov NCT04985305. Registered on 30 July 2021.

Using Shared Decision-Making Resources in Long-Term Care: a Qualitative Study

“…Ongoing work in the field of SDM in LTC includes a Danish complex intervention using health-care provider education, a reflection tool for staff to evaluate symptoms, and a dialog tool to facilitate conversations with residents/caregivers about use of psychotropic medications in residents with dementia. ( 27 ) Future implementation efforts for SDM likely requires this type of active complex intervention, including supports such as education/training for health-care providers, staff and residents/caregivers, coaching/facilitation, decision-support tools and other structures to facilitate SDM.…”

Factors promoting and impeding efforts to deprescribe antidepressants among nursing home residents with dementia– a process evaluation guided by normalization process theory

“…A detailed description of the main trial and the development of the intervention is reported elsewhere [ 32 , 37 ]. To summarize, the trial was conducted as a cluster randomized controlled trial with GPs working as nursing home physicians as the clusters.…”